For some time the three of us have been deeply
engaged in exploring the implications of a social constructionist view of
knowledge for therapeutic practice. From a constructionist standpoint, our
languages for describing and explaining the world (and ourselves) are not
derived from or demanded by whatever is the case. Rather, our languages of
description and explanation are produced, sustained, and/or abandoned within
processes of human interaction. Further, our languages are constituent features
of cultural pattern. They are embedded within relationships in such a way that
to change the language would be to alter the relationship. To abandon the
concepts of romance, love, marriage and commitment, for example, would be to
alter the forms of cultural life; to obliterate the languages of consciousness,
choice, or deliberation would render meaningless our present patterns of praise
and blame, along with our courts of law. By the same token, as we generate new
languages in our professions, and disseminate them within the culture, so do we
insinuate ourselves into daily relations - for good or ill. It is against this
backdrop that the three of us wish to consider the issue of diagnosis in
general, and relational diagnosis in particular. We opt for the trialogic
conversation as a means of vivifying in practice (as well as in content) the
constructionist emphasis on meaning through
relationship.

KJG: I
find myself increasingly alarmed by the expansion and intensification of
diagnosis in this century. At the turn of the century our system for classifying
mental disorders was quite rudimentary in terminology and not broadly accepted.
However as the century has unfolded, the terminology has expanded exponentially,
and public consciousness of mental deficit terminology has grown acute. In the
1929 publication of Israel Wechsler's The Neuroses, a group of approximately a
dozen psychological disorders were identified. With the 1938 publication of the
Manual of Psychiatry and Mental Hygiene (Rosanoff, 1938), some 40 psychogenic
disturbances were recognized. (It is interesting to note that many of the terms
included therin, such as paresthetic hysteria, and autonomic hysteria have since
dropped from common usage, and some of them - such as moral deficiency,
vagabondage, misanthropy, and masturbation - now seem quaint or obviously
prejudicial. In 1952, with the American Psychiatric Association's publication of
the first Diagnostic and Statistical Manual of Mental Disorders (APA, 1952) some
50-60 different psychogenic disturbances were identified. By 1987 - only twenty
years later - the manual had gone through three revisions. With the publication
of DSM IIIR (APA, 1987) the number of recognized illnesses more than tripled
(hovering between 180-200 depending on choice of definitional boundaries). DSM
IV expands the list even further (APA, 1994).

At the present
time, one may be classified as mentally ill by virtue of cocaine intoxication,
caffeine intoxication, the use of hallucinogens, voyeurism, transvestism, sexual
aversion, the inhibition of orgasm, gambling, academic problems, antisocial
behavior, bereavement, and noncompliance with medical treatment. Numerous
additions to the standardized nomenclature continuously appear in professional
writings to the public. Consider, for example, seasonal affective disorder,
stress, burnout, erotomania, the harlequin complex, and so on. What, we might
ask, are the upper limits for classifying people in terms of
deficits?

As these
terminologies are disseminated to the public - through classrooms, popular
magazines, television and film dramas, and the like - they become available for
understanding ourselves and others. They are, after all, the "terms of the
experts," and if one wishes to do the right thing, they become languages of
choice for understanding or labeling people (including the self) in daily life.
Terms such as depression, paranoia, attention deficit disorder, sociopathic, and
schizophrenia have become essential entries in the vocabulary of the educated
person. And, when the terms are applied in daily life they have substantial
effects - in narrowing the explanation to the level of the individual,
stigmatizing, and obscuring the contribution of other factors (including the
demands of economic life, media images, and traditions of individual evaluation)
to the actions in question. Further, when these terms are used to construct the
self, they suggest that one should seek professional treatment. In this sense,
the development and dissemination of the terminology by the profession acts to
create a population of people who will seek professional help. And, as more
professionals are required - as they have been in increasing numbers over the
century - so is there pressure to increase the vocabulary. Elsewhere (Gergen,
1994) I have called this a "cycle of progressive infirmity."

LH:
Ken's thinking has been most helpful in my particular struggles to find a way
out of the naming bind, which is the belief that in order to be helpful about a
complaint, you have to describe it and name it. The describing and naming makes
it real. Medical practitioners have been so successful in creating a taxonomy of
physical distress that psychological professionals have sought to follow
suit.

There is an
implicit contradiction between the non-essentialist stance of social
construction theory and the present volume on relational diagnosis. If social
construction theory challenges psychobiological naming systems, it also
challenges the descriptive truth of a relational syllabary. None of these
self-confirming systems of naming provide a comfortable resting place for the
social constructionist. At the same time, what is to become of the profession of
family therapy if it doesn't join in the practice of naming? The threatened
extinction of our way of life is at stake.

Trying to think
why I was drawn to social constructionism, I reflected that I had been through
several "diagnostic worldviews" in my lifetime, each more convincing than the
last, and was beginning to see this as evidence of a very relativistic and
joking cosmic God. As far as psychology was concerned, I had come of age in
total innocence. The community of left-wing artists I grew up in had their own
brand of qualifying phrases: reactionary, fascist, business man, Republican,
Philistine. Only when I got to college did I find out about neuroses and
psychoses and "mental illness." My earlier worldview took a hit, in addition to
which I found that many of the new terms could describe myself. My discovery of
the family therapy movement, which took the onus off the person and put it on
the "system," was therefore a great relief.

I felt pleased
with myself as the family systems movement gathered speed. Then I was challenged
again. I discovered an article by a scholar from Ontario, Gerald Erickson (1988)
who attacked systemic thinking from a postmodern point of view. As I scrambled
to read about these new ideas, I realized that all of the models in the family
therapy field had great failings. They were all modernist and mistaken. There
were no systems out there, no patterns that connect, no levels, no structures
waiting to be observed. For me this kind of thinking put an end to diagnostics
of any kind.

This is a bit
tongue in cheek, but I assure you that each epistemological earthquake leaves
enormous damage in its wake. Every time you build a world of ideas or join one,
it is like a screening device that limits you from seeing other worlds. Out of
sight are those you left behind or those you uneasily suspect may lie ahead.
There is also a gathering coherence that seems to go with the territory. As time
passes, this coherence may become increasingly well defined and more fully knit.
That is why it is only necessary to damage one piece of a world to bring down
many related structures.

Nevertheless,
these worlds have enormous resiliency. In my lifetime, in the field I am in, I
have been shaken by earthquakes several times. I have tended to move on to a new
community, but many of the inhabitants of the old ones have rebuilt and gone on
as before. It takes an earthquake that strikes at a deep structure level, like
finances, to mark historic change. The health care upheaval, for better or
worse, has given one of the cities in my field a mandate to be the capital.
Gathered under the medicalized roof of DSM IV, we find an attempt to enumerate
and describe all existing problems of behavior: life problems, death problems,
mind problems, disease problems, poverty problems, class problems, violence
problems, sex problems, work problems, love problems. We see the proliferation
of pathological titles Ken has talked about, and there seems no upper limit on
what can be absorbed into the system of naming.

At the same
time, I think this may be the good fortune of family therapists. Conditions that
are "merely" relational have been exempted from inclusion in DSM IV, except for
a brief nod to a relationship-oriented axis that may not even be reimbursed. So
perhaps we have been rescued from the "rage to order." Harlene Anderson (1994)
and Ken Hardy (1994) were recently asked to answer the charge that family
therapy would be marginalized unless it became more identified with the "major
disciplines" in mental health (Shields, Wynne and Gawinski, 1994). So much the
better, they said. Only by remaining the one health industry that does not give
people labels or diagnose conditions, can it represent an important stream of
evolution in the field. That is my position too.

HA: The
passionate plea for the inclusion of relational diagnoses in the DSMIV locates
family therapy within psychiatric discourse, with its medical heritage, its
aspiration to mimic natural sciences, and its modernist, positivist disposition.
This is understandable. As Ken suggests, diagnostic systems give a sense of
legitimacy, confidence and predictability both to the professional and to the
client. In both psychotherapy and the broader culture, a diagnosis implies that
the object of inquiry and the method of inquiry are based on stable assumptions
like those in the biomedical realm. It operates as a professional code which has
the function of gathering, analyzing and ordering waiting-to-be-discovered data.
As similarities and patterns are found, problems are then fitted into a
deficit-based system of categories. In a larger sense, this framework is based
on the assumption that language is representational and can accurately depict
"reality." When I think of diagnosis, I think of cybernetician, Heinz von
Foerster's remark, "Believing is seeing."

Implicit in the
DSM IV is the assumption that psychotherapy is a relationship between an expert
who has knowledge and a non-expert who needs help. The public, the profession
and the state have given authority to the therapist to collect information about
the client and place it on a pre determined therapist map from which the
diagnosis is then derived and the treatment plan decided. This process reduces
uncertainty by telling the therapist what the therapist ought to do and
suggesting how the client ought to change in order to get
well.

From a
postmodern perspective, a relational or "between persons" diagnosis is no
different from an individual or "within-the -person" diagnosis. The inclusion of
family therapy criteria for "behavioral health" would simply place a new layer
of labels upon an old one. For political, economic, and legitimation reasons,
this would be a great step forward for family therapy, but in terms of its
heritage as an alternative explanatory view, it constitutes a great step back.
Simply to assume that the issue is a question of an individual versus a
relational classification is to oversimplify a set of complex, ever changing
human dynamics.

If one
approaches these questions from a postmodern, social constructionist
perspective, these are no longer relevant questions. Social constructionism
frees one to think in terms of individuals-in relationship rather than an
individual-relationship dichotomy. It also locates psychological knowledge in a
socio-historical context and treats it as a form of discursive activity
(Danziger, 1990, Luria, 1971; Gergen, 1973, 1985). Discursive activity refers to
Wittgenstein's (1962) challenge to see language as representational - an
expression of the nature of things - and his alternative idea that we generate
descriptions and explanations in the means of coordinating ourselves with each
other. It is the language that constructs what we take to be the person and the
relationship. Diagnoses, for instance, are socially constructed meanings put
forth by the dominant professional culture. A diagnosis is an agreement in
language to make sense of some behavior or event in a certain way. But a social
constructionist perspective warns us that this kind of agreement may mislead us
into holding the diagnosis to be true. Is it the diagnostic reality we should be
treating in therapy?

Social
constructionism invites alternative questions: What is the intent of a
diagnosis? What questions are believed to be answered by diagnosis? What
information is thought to be gained? What does one want a diagnosis to
communicate and to whom? If there are many ways to think about, to describe what
may be thought of as the same thing (i.e., behaviors, feeling), how can we
respect and work within all realities? Should we consider the possibility of
multiple diagnoses? How can we bring the client into the process? How can, and
is it possible, for a diagnosis to be meaningful for all involved? How can it be
collaborative, tailored to the individual, useful? What other words can we use?
If we reject diagnostic terms, should we try to persuade the helping system to
change its nosology? How do we develop a way in which multiverses can
co-exist?

If one views life
as dynamic, unstable, and unpredictable then inquiry about it must be ever
active. If one views knowledge as socially created and knowledge and knowers as
interdependent, then it makes sense to include the client in the diagnostic
process. This moves diagnosis from the realm of a private discourse to a shared
inquiry in which diagnosis becomes a mutual discovery process.

In a
serendipitous way clients have become involved in creating their own diagnoses
and ideas about treatment. Our culture-bound human nature compels us to want to
know what is wrong, to have a name for a problem. With the help of the media,
diagnostic language and preferred treatments have leaked into the public domain.
We all have clients who come in with self-diagnoses such as "co-dependent" and
"adult child of an alcoholic" and clients who request Prozac for depression or a
twelve step group for addiction. I question, however, whether these
self-diagnoses do not often yield unworkable problems for both the client and
the professional. Diagnoses, official and unofficial, often concretize
identities that limit people; they create black boxes with few, obscure exits;
and they form obstacles to more viable and liberating self definitions
(Anderson, 1992).

I recently
talked with a couple who had appeared on a television talk show focused on
gender issues in couples. The show's guest expert had diagnosed the husband as
"irresponsible" (an individual description), the wife as an "adult survivor of
childhood incest" (an individual description) and the couple as "co-dependent"
(a relational description). When I saw them they were embroiled in a battle to
make him responsible, to promote her "survivorhood" and to make them independent
of each other. They were prisoners of diagnosis-created unworkable problems. Or,
as Ken Gergen suggests, every move they made was dysfunctionalized. This is the
tyranny of diagnosis.

Thinking of therapy
and diagnosis from a postmodern social constructionist perspective redefines the
therapist-client relationship and challenges professional knowledge. It moves
therapy from a relationship between a knower and on who is ignorant to a
collaborative partnership in which the deciding of, the exploring of, and the
"solving" of problems is a process of shared inquiry in which the diagnosis is
not fixed and the problem may shift and dissolve over time. It invites the
client's voice and their expertise on their lived experiences. Bringing in the
client's voice - the words and terms that have significance for the client -
gives productive life to everyday language. The yield is a more jointly created
and thus more cooperative language, that generates more possibilities than
professional vocabularies - based on pre-knowledge that produces lifeless,
sterile look-a-likes - and suppresses the uniqueness of the individual client's
narrative (Anderson, 1992). A constructionist stance favours a more mutual,
personalized knowledge. This view of therapy and diagnosis entails uncertainty,
and I realize that some might question this ethic of uncertainty, but I question
the ethic of certainty.

This is why I
do not favour adding a "relational diagnosis" to the one already in use. Kaslow
(1993) envisages the "formulation of a language and a typology that can be
utilized, with a high degree of consensus about definitions and criteria sets,
based on solid research findings, by family therapists emanating from many
disciplines and theoretical persuasions" which would eventuate in a "validated
nosology of relational disorders." There are many reasons, both theoretical and
practical, for doubting this possibility; and there are many reasons for arguing
against such an end. Like Ken and Lynn, I suggest that rather than talk about a
relational diagnositic system, we need to consider new and more promising
directions for family therapy and psychology.

Of course this
leaves us shaken. Many questions are left hanging. What do therapists do with
their professional knowledge and past experience? How do we then communicate
with professional colleagues, clients and insurance companies? The ethical
questions that face us in this new era of managed health care are far broader
and more daunting, for instance, than simply whether submissions for insurance
reimbursement are factually correct.

KJG: As
I have been deliberating on your comments, Lynn and Harlene, I have been trying
to take the role of an essentialist, diagnostician, and asking myself what
questions I would raise. One of these is a question I have often faced myself,
and it concerns the existence of what we would generally take to be "the real
world." In more homely fashion, one asks "isn't there something these terms
refer to, and aren't these kinds of behaviors deeply problematic both for the
individuals (or families) as well as the society? We must have some way to talk
about these patterns within our profession, some way to share our knowledge of
effective treatment. So don't we require just these forms of terminology?" And,
such an interrogator might add, we need such terms even if we agree with the
constructionist argument that these may not be the only or the most accurate
ways of describing such actions.

I would view
this as a reasonable question, granting that we spend most of our time in
cultural traditions where the "real world" counts. However, granting in this
sense that there is "something these terms refer to," the question becomes, as
you suggest Harlene, whether and for what we require the professional labels? At
the outset, the argument simply doesn't hold that the diagnostic terms describe
observable behaviors. None of our terms, either from DSM IV, or from the newly
developing vocabulary of relational diagnosis, actually refer to the specific
movements of people's bodies through time and space, the sounds they emit, the
liquids or smells they exude - or anything else we could assess with a set of
mechanical instruments. Rather, they refer to hypothetical processes,
mechanisms, or purposes lying behind or served by a set of behaviors. If I say
an individual is "depressed," based on a set of items from a depression
inventory, it is not the checkmarks on the paper to which I am referring but
what these checkmarks suggest about a state of mind. Yet, I have no access to a
state of mind; this I presume a priori (or you might say, because of the
particular myths about the mind which I inherit from cultural history.) In the
same way, I don't as a therapist observe dysfunctional behavior. I observe
behavior which I label as dysfunctional given a set of values which I hold about
what is functional. To be sure, these are academic arguments simply designed to
deflate the presumption that professional labels have unambiguous referents (see
also Sarbin and Mancuso, 1980; Wiener, 1991). However, shortly I will propose
that because of this problem, the therapeutic community stands in great
danger.

Now, if our labels
are but scantily tied to observables, the question of "why label" takes on new
dimensions. We can not say that we need the labels to communicate professionally
about the cases we confront, because there is no grounds to believe that what
you mean (in terms of specific behavior) by "oppositional defiant disorder," or
"partner relational problem" is the same thing that anyone else means; and
should we agree, there is no means of substantiating this conclusion outside our
local agreement. Thus, the diagnostic terms help us to think that we are all
working on the same phenomena, but this is to create a false sense of security.
Do the professional diagnoses then help the client? Surely this is the most
significant question we should be asking. There is reason for debate here, for
some clients may indeed prefer the security of a professional term to replace
what they feel are their own floundering attempts to comprehend. The
availability of the diagnosis suggests that such cases are possibly common, well
known, well understood, and quite effectively treatable. And, while to give a
diagnosis under such conditions would be an act of bad faith on the therapist's
part, there might be ameliorative placebo effects.

At this point I
am drawn to the wisdom of Harlene's comments concerning the ever-shifting
character of daily activity, the communal construction of meaning, and the ways
in which languages function in daily life. For, it might be asked, in the long
run is it not a greater contribution to the lives of our clients (and indeed our
own), if we have multiple ways of understanding our activities, if we can see
how different groups might describe what we do, if we understand how these
various descriptions add or subtract from life's quality? Most of us are fully
aware that we ourselves are too complex to slot into categories, that
relationships are subject to infinite interpretation, that the same actions and
the same descriptions may mean different things at different times and with
different consequences. Would we not wish our clients to take advantage of these
forms of cultural wisdom? In whose service do we "freeze the
frame?"

Earlier I
mentioned the possibility of danger. Both Lynn and Harlene endorse a field of
family therapy that is unique in its avoidance of a professional nosology, a
field that in my opinion would thus be at the cultural forefront. In the long
run there is reason to believe that the other helping professions will follow
suite. For there is much grass roots antipathy developing for the kinds of
diagnoses to which patients have been exposed over the years, organizations of
ex-mental patients who feel they have been ill served by the practices of the
mental health professions (Chamberlin, 1990), and feminist groups who feel women
to be victims of the existing nosologies (see, for example, Caplan, 1987; 1991).
And there are professionals from around the globe who (like us) feel that
diagnostics are more injurious than helpful. The day will soon come (and indeed
I will lend my efforts to the outcome) in which those who require assistance for
their problems will bring formal litigation against those who diagnose. When
diagnostic categories become part of one's permanent records, and such records
become available for various evaluative purposes, the mental health profession
will have no legitimate grounds on which to defend the practice of
diagnosis.

LH: I
agree with your warnings, Ken and Harlene, about the harmfulness of diagnostic
labeling, or what I call "psychiatric hate speech". To find out what is actually
experienced as hateful, I have been experimenting with consultations in
workshops. I will talk with a therapist about a family situation (I have
abandoned the term "case") while the family is sitting there overhearing us. I
will then ask the family to comment on our conversation. Next I will ask the
audience, in small groups, to arrive at some ideas to reflect back to the
family. The groups take turns telling me their ideas, which I write down on a
flipchart, but only after these are filtered through family members' reactions.
This has been a very interesting procedure, in that we create a family-sensitive
set of descriptions rather than the usual professional ones imposed from
outside. I remember one incident involving a stormy couple who couldn't stay
together and couldn't stay apart. One audience group had commented that the
couple seemed to have an addiction to crisis. Another group, referring to a
local spot which was known as the Bungee Capital of North America, likened their
relationship to a pair of married bungee jumpers. The couple objected to the
first idea, but warmly accepted the second. Operations like this replace the
usual expert model for diagnosis with a less pejorative one.

In doing
homework for this piece, I found myself examining some of the more relational
schemes for diagnosis. One that actually made it into the DSM IV (1994), at
least into the Appendix, is family psychiatrist Lyman Wynne's "Global Assessment
of Family Functioning Scale" (GARF) which parallels the "Global Assessment of
Functioning Scale" (GAF) for individuals, reported under Axis V. GARF reflects
the early thinking about family therapy that was based on the idea that the
family is a "system", that is, a unit composed of subparts acting
interdependently upon each other. This analogy was apparently contributed by
Talcott Parsons (1951), whose normative model for family functioning was a
powerful image in the field until recently, when the late psychologist Harold
Goolishian (1988) challenged it.

Another effort
to create a relational framework for diagnosis has been offered by Karl Tomm
(1991), a psychiatrist from Canada. Tomm believes that a family in which there
is a patient is one in which the communication is dominated by harmful patterns.
These patterns are not produced by the family system per se, but are a result of
vicious cycles in which efforts to stop the pattern only reinforce it. Tomm
calls these sequences Pathological Interpersonal Patterns (PIPs), and sees
therapy as a matter of replacing them with Healing Interpersonal Pattern (HIPs).
As a constructionist, I find both Wynne's and Tomm's formulations an improvement
on DSM IV's categories in that they are not so unkind to the individual, but I
still feel uncomfortable with their assumption of an ontologically transparent
pathology.

Fortunately,
the recent jump to a narrative analogy has put diagnosis on a new track. This
track jettisons the notion of an objective assessment of pathology, preferring
to think of these formulations as stories, or forms of discourse. In one swift
shift of metaphor, we are catapulted into a postmodern universe where "reality"
is placed in quotes. White and Epston (1990), among others, shoved the canoe
from the bank by opposing the "problem-saturated" story and joining forces with
the family to find a new, more hopeful one. A kindred soul to White is Chris
Kinman of British Columbia. In working with First Nations youth, Kinman has been
very concerned to help create alternatives to the usual stereotyped pictures of
problematic teens. While trying to come up with a narrative based set of
diagnostic tools, he has been experimenting with the term "discourse," using it
to frame the situation of a young client by locating it under headings like,
"Discourses of Youth and Peers" or "Discourses of Youth and School" (Kinman and
Sanders, 1994). These descriptions are arrived at by conversations with the
individual in question and with other people in the family or
community.

I mention these
efforts because even though many of us deplore the psychiatric profession's
extraordinary attempt to cover all bases in a grab for territory, the appearance
of DSM IV has acted as a most important gadfly. The field of family therapy
seems to have been preparing itself for this fight in view of the increasingly
swift acceptance of a social constructionist and narrative point of
view.

I would like to
make one last point in saying that this constructionist view is congruent with
the movement toward user friendliness in family therapy (Reimers and Treacher,
1995). A recent news report on malpractice suits against medical practitioners
found that the number of suits correlated with a poor "bedside manner": those
who take time with their patients, listen attentively to them, and show
kindness, are sued far less often than their brusquer counterparts. In an era of
managed care, the client's story is going to be listened to more carefully, and
there will be a move toward including the user in the conversation, especially
the conversation around diagnosis.

At the same time,
even when I disagree with a position, I like to join with what is already in
place. In this respect, I find that the structuring of diagnosis around axes of
varying hues offers a useful starting point. It is easy to imagine this format
transforming into a Roshomon-like array of differing perspectives. Customers
could have a special axis to themselves or a separate place to comment on each
axis. Since the process of definition is the primary framing act of any kind of
therapy or consultation, it deserves as much time as is needed. Attention to
this aspect seems to me crucial, not only in exposing the bedrock nature of
therapy as a political as opposed to a medical event, but in allowing all
parties to have their day in court.

HA: I am
particularly captured by Ken and Lynn's interest in the client's voice--the ways
in which some clients either jointly through organized associations or
singularly through the courts are securing an arena for the consumers'
sentiments and grievances. Ken speaks of the days of litigation to come. I think
they have already begun. Media reports of patients suing therapists (and
winning) are no longer an anomaly. We read reports of patients who sued
therapists for creating false memory syndromes and multiple personalities.
Recently parents sued their sixteen year old daughter's therapist for not
thoroughly investigating her accusations of sexual abuse. Such actions threaten
the false sense of security that diagnosis gives the professional and highlight
the complexity of human behavior and interactions. Likewise, such actions shout
the importance of guaranteeing the consumer's voice, be it client, insurance
company, managed health care agent or therapist.

Like Lynn, I am
drawn to the hope that a narrative perspective can provide a possible relief
from the deficiency and illness language in the mental health field. Narrative
understanding takes into account the beliefs and intentions and the narrative
histories and contexts that underpin, shape and give significance to those
actions. As such, narrative understanding offers the possibility of
understanding, and equally important, not understanding the actions of others. I
would like to echo Goolishian's comment in his plenary paper for the Houston
Galveston Institute's conference, The Dis-diseasing of Mental Health, held in
October, 1991. He said, "We must rely on the capacity that people have for the
narrative construction of their life and we must redefine therapy as a skill in
participating in that process...It will take more than relational language...We
must develop a language of description that moves us out of the linguistic black
hole in which we are now captured." Inspired by Wittgenstein's words in Culture
and Value:

Nobody can
truthfully say of himself that he is filth.

Because if I do say
it, though it can be true in some

sense, this is not
a truth by which I myself can be penetrated;

otherwise I should
have to go mad or change myself.

Goolishian
continued, "Our languages of description are not only normative but they have,
over the years, ended up forcing socially constructed self narratives on our
clients of uselessness and filth." Is it possible that as a result they often
select the option "to go mad?"

KJG: One
hope that the three of us shared in this effort, was that the trialogue as a
form of writing would itself demonstrate some of the advantages of a
constructionist orientation to relational diagnosis. What happens if we depart
from monologue (which parallels the singular voice of diagnostic labeling
practices) and approach a multi-vocal conversation (favored by the
constructionist)? In some degree I think we have made good on this hope,
inasmuch as each of us has brought a unique voice to the table, drawing from
different experiences, relationships, and literatures. Our case is richer by
virtue of our joint-participation. At the same time, because there is so much
general agreement among us, the trialogic form hasn't blossomed in fullest
degree. We have not yet cashed in on its catalytic potential.

To explore this
possibility, I want to focus on a point of disagreement. How can we treat
conflict within this conversational space in a way that is different from a
monological orientation (where the interlocutor typically shields internal
conflicts in favor of achieving full coherence)? The fact is that I do not in
the case of diagnostics favor Lynn's preference for joining "what is already in
place." As she points out, "the process of definition is the primary framing act
of any kind of therapy or consultation," and, by virtue of our various
critiques, proposes to multiply the range of definitions, even to include those
of the clients themselves. Perhaps I feel more critical toward diagnosis, but I
ask, if it is injurious to our "clients," why join what is in place? Why should
we accept the process of definition as a primary feature of therapy or
consultation?

Now I realize
that it is perhaps easier for me to take this strong position, because I am not
a therapist and do not depend on maintaining the therapeutic traditions for my
livelihood. I need not be so concerned with what is already in place because I
have fewer worries about what it does to my relationships within the tradition
(and my family) should I deviate sharply from it. And too, we have already seen
Lynn's concern that the profession maintain itself in a realistic world of
competition with the more diagnostically prone mental health professionals.
Thus, as a constructionist I must understand the intelligibility of Lynn's
preferences in terms of the relational matrix in which she lives. And vice
versa. But where does such recognition take us? And, to play out the parallels
with professional-client relations, what might follow if both the professional
and the client realized the parochial nature of various diagnostic labels,
respecting each other but realizing that such understandings represent only one
tradition among many?

There is no
single answer to these queries. The more general question of how to go on in a
world of multiple and conflicting realities is as profound as it is complex.
However, let me suggest that at least one possibility in the present instance is
to locate an alternative intelligibility with which we can both live
comfortably. I am thinking here primarily in terms of clinical practices. It
seems to me that we might share in the belief that the process of labeling may
sometimes have value, that it is sometimes injurious, but that it is not
essential to the process of therapy. That is, therapeutic efficacy does not
depend chiefly on slotting clients into a set of predetermined and publicly
acknowledged categories. If we could agree on this assumption, then we might ask
whether it would be possible to establish some form of "no fault" insurance
coverage for therapy. Such policies have been a major boon to divorce courts,
where establishing the original source of marital problems has proved
impossible. We enter much the same thicket in attempting to diagnose "the
problem" in cases of most human suffering. If insurance companies no longer
required diagnoses for third party therapy billings, then diagnosis could become
optional - available when useful but not essential for treatment. If every
insured party in a given insurance plan had the right to a limited number of
consultations, then the fact that the individual (or family) felt their
suffering was severe enough to demand professional attention might be
sufficient. Might we explore the possibilities together of instituting such
policies across the mental health professions?

Reflexively
speaking, it seems to me that our present trialogue has now managed to press our
joint thinking on these topics forward - so that the three of us are changed
during the course of our conversation. I am not in precisely the same place I
was when I entered the conversation. If this is so, is there not a lesson here
for the traditional tendency in the profession toward monologue? Diagnostic
labeling has a way of "stopping the conversation." The professional announces
"you are X" or "Y" and there is no obvious means of the diagnosis being
transformed by the subsequent conversation with the client. Monologue insulates
itself from change; diagnostics radically truncate the possibilities for
therapeutic transformation.

HA: Ken
suggests that our trialogue has not created the catalytic potential that hoped
to achieve. For me, it has created more thoughts than my written words reveal. I
have more of a dialogue in my head about diagnosis, and I frequently bring the
issues of diagnosis into my conversations with colleagues and students. As in
therapy, is the catalytic potential ever visible? Can our words on paper further
the dialogue about diagnosis for others? I hope so.

I will tell a
story about a case that vividly illustrates the complexities of human problems
and how diagnosis and diagnosis driven treatment can oversimplify and exacerbate
them: "I asked my daughter, why do you have this exotic white woman's disease?"
These words were spoken by the exasperated father of Joan, a sixteen year old
Afro American girl who, in her efforts to control her weight, was starving
herself to death. She met the essential criteria for Anorexia Nervosa. Joan was
hospitalized a year ago at a private psychiatric hospital where her treatment
included individual, family and adolescent group therapy. She was discharged
after 30 days when her psychiatric hospitalization insurance benefits were
exhausted and admitted to a private hospital medical unit where her problem was
diagnosed as a medical disorder. She was discharged after one week when the
insurance company challenged the medical diagnosis, having determined it was a
pre-existing psychiatric diagnosis, and therefore denying
coverage.

The hospital
physician urged the family to commit their daughter to a county charity
psychiatric hospital where she could receive psychiatric care for 30 days at no
charge. The family refused. The physician said that Joan was "the most
difficult" and "the most devious anorectic" that he had treated. He feared she
would "slip through the cracks" if she did not receive continuous inpatient
psychiatric treatment. His fear was corroborated by her and the family's
behaviors. In talking about the family he said frustratedly," We're not on the
same page of the book. No, we're not even in the same book." He believed that
the father's responses did not match the daughter's life-threatening illness,
and his belief was validated each time the father, who was a minister, talked
about spirituality and expressed his faith in his daughter's "finding her way"
and "trusting the process." The physician was also frustrated with and puzzled
by the family's insincerity and by a family in which the father was more
absorbed with the daughter's eating disorder than the mother. He said the
father's calmness, as he described the father carrying his limp daughter into
the hospital emergency room, was "bizarre."

Two weeks after the
medical hospital discharge Joan drank a bottle of syrub to induce vomiting, and
began vomiting uncontrollably. Her parents took her to the county charity
hospital where she was admitted because the staff thought Joan was suicidal.
Joan insisted that she was not trying to kill herself. In the county hospital
she had individual therapy and was discharged after two weeks with the condition
that her family agree to engage in intensive family therapy. She was referred to
a private psychiatric clinic whose intake screened her out because the insurance
benefits were exhausted. The private clinic, in turn, referred Joan to a
non-profit counselling center. The referral was made to a specific
therapist-in-training who the intake person at the private clinic knew had
personal experience with an eating disorder. Joan's parents took her to see the
counseling center therapist where it was agreed that the therapist would
continue to see Joan and that the parents would meet with the therapist whenever
the therapist, Joan, or the parents felt it necessary.

The family
continued to consult their family physician who felt Joan's problem was out of
his realm of expertise. He referred Joan -- simultaneously with the referral to
the non-profit counseling center -- to a private practice therapist who
specialized in eating disorders. The family took Joan to the specialist who
added the diagnosis Major Depression, Single Episode and initiated individual
therapy for Joan and family therapy for her and her parents. He too said that
the family was "the most bizarre family I have ever seen." He felt that Joan had
"too much power over her parents" and was "victim" of, and in turn was "acting
out her parent's estrangement and conflict." When he found out that the parents
had authorized a home-bound school program for Joan he warned the counseling
center therapist that "Joan must go to school...don't you know that anorectics
manipulate and isolate." He saw the school decision as evidence that Joan had
too much power over her parents and now the counseling center therapist and her
supervisor.

The private
therapist continued to see Joan and the family and the counseling center
therapist continued to see Joan, sometimes twice a week, and to occasionally
meet with members of her family in different combinations. Who came to the
sessions depended on what as being talked about and who wanted to come. The
counseling center therapist thought the parents were cooperative. They always
kept their appointments and often requested additional appointments. Dad usually
brought Joan to the sessions because mother worked and went to
college.

Joan talked with
the counseling center therapist frequently about the people who were "bugging"
her by trying to be helpful. Referring to a previous therapist, Joan said, "He
thought he knew all about me just because I'm an anorectic." She talked about
how he confronted her and accused her of being secretive, isolating, and
dishonest. She wished people would let her be herself.

The therapist
asked curiously, "How do I treat you?" Joan said, "I like working with you
because you don't treat me like I'm an anorectic. You let me by myself." Joan
talked about how she wanted to be a teenager with teenage problems, how she was
worried about the way she expressed her anger, and how ill at ease she was with
what her peers were doing. She expressed anxiety about social awkwardness, boys,
the dark, being lonely, expectations at home that she should take care of her
younger brothers, taking up slack for chores her sister did not do, and wanting
a job to earn some money. She said she felt like an "ugly duckling" and that
people always commented on how pretty her sister was. She said, "I want to be an
individual where others cannot copy me." Joan expressed concern about her
parent's relationship, worrying that they were "so distant" and that "mom buries
herself in her work" and described how her mother's "stacks of paper had taken
over the house." She expressed her worry about how her parents get "so stirred
up" when they talk with the eating disorder therapist.

The therapist's
curiosity about the father's question, "Why do you have this exotic white
woman's disease?" led her to learn that the family lived in an all white
neighborhood and that Joan had all white friends. (Joan did not see the racial
issue as a problem the way her father and brother did). She learned that the
father was a prominent black minister and that the mother was a devout Catholic.
The daughter went to church with the mother and the son went to church with the
father. The father, persuaded by his religious beliefs, felt that the daughter's
illness was "the work of the devil." "All things happen for a purpose...God is
testing her strength," he said, and he backed up his belief with Biblical
quotes. He was firm in his belief that "This is something she is working out..I
trust her that she will work through this..trust her to make decisions about
what is best for her..to find her own way."

The mother
seemed genuinely concerned, "I want Joan to feel that I am here for her." (Of
course, Joan thought the mother was "intrusive.") The mother hoped that the
therapist could "help Joan with her emotions" and could "help Joan talk with the
family about what is really bothering her." Joan's sister, like her mother,
thought it would be helpful "if she would just talk to us about
it."

Joan's older
brother pinpointed the stressful relationship between Joan and her younger
sister as the culprit. He felt strongly that if they were in a school where the
majority of students were black that Joan, and her sister as well, would not
have problems or the split between them because "In an all black school you have
to stick together to protect yourself." He had several other thoughts about
Joan's problem -- all relating to cultural issues. He agreed with the dad that,
"Black girls don't have anorexia."

In reflecting
on her work with Joan and her family, the counseling center therapist said, "At
first I took the diagnosis that the family and I had inherited seriously. I
believed it. Influenced by my preconceptions of anorectics as rigid,
controlling, isolating, perfectionists, I did not question the psychiatrist's
and the eating disorder specialist's opinions and recommendations. I tried hard
to help Joan and her family. I tried to talk with Joan and her family about the
diagnosis and convince them of the experts' opinions on the individual and
family dynamics associated with anorexia nervosa. The harder I tried, the worse
Joan became, and the more upset and worried I became."

Like the others
before her, the more the therapist tried to treat the diagnosis the more family
members acted in ways that verified her preconceptions about anorectics and
their families and hence confirmed the diagnosis. Frustration mounted until, as
the therapist put it, "As I got to know Joan and her family, I gradually
realized that I was getting to know another Joan, another mother, and another
father. My interest in what they were concerned about led to conversations in
which Joan and her family found causes and answers that were meaningful to them.
To my surprise I too was beginning to trust that Joan would find her answers and
her own way. I realized that I was seeing and hearing the person not an
anorectic and a dysfunctional family."

Through the
therapist's inquisitiveness about each person's ideas, she learned far more
about the family and its members than simply pursuing what the diagnosis
permits. The dysfunctional nonsense of their actions and beliefs now made sense.
As the therapy with Joan and her family illustrates, there are as many
definitions of "a problem," including what caused it and its imagined solutions,
as there are people in conversation about the problem. And these ideas can
change over time.

As I think
about Joan and her family I keep returning to the notions of monologue and
dialogue that Ken mentioned. Embedded in my earlier comments is a bias toward
the process, or the essence, of therapy as a dialogue. Diagnosis is part of this
dialogue. Preconceptions can lead a therapist to an inner monologue and can lead
to duelling monologues between client and therapist - and among professionals.
The therapist's ability to question and not hold onto her preconceptions allowed
her to be open and curious about others. Joan and her family and the therapist
joined in dialogue - a conversational process involving a shared inquiry that
led to shifts in the "problem" and new possibilities for all of them. This leads
me to Lynn's comment on joining.

I am not sure
if by joining Lynn means agreeing with or using as a starting point for
conversation. Nevertheless, I do not believe that diagnosis or problem defining
necessarily need to be part of the therapy, although clients do usually want to
talk about their problem. That is why they come. How problems and solutions
emerge and dissolve through dialogue, however, is beyond the scope of this
trialogue. (See Anderson and Goolishian, 1988; and Anderson, 1995.) I agree that
thinking of diagnosis in terms of either-or oversimplifies and clouds. Several
questions have been intimated in this discussion on diagnosis and I think are
worth highlighting. If there is a diagnostic process, toward what aim and who
determines that aim? What meaning does the diagnosis have for each person
involved? Most importantly, what meaning does it have for the client? Is it a
useful meaning? Is it respectful? Does it allow for the opening of doors - the
creation of potentials - or does it close doors and restrict possibilities? Does
it perpetuate the problem? Does it create new problems? These are the questions
we should confront prior to developing yet a new range of
diagnositics.

Lynn mentioned
managed health care. I think that managed health will further marginalize the
client's voice. Managed health care is already dictating and policing diagnoses.
It is not unusual for a managed health care company to refuse to authorize
services except for the diagnosis assigned by their case manager. Therapy is not
only a political and a medical event but also an economic event. But this leads
us to another topic.

LH: It
does seem that the conversation is now taking us into new spaces. The question I
have is whether the shift would have happened if I had not "joined the
opposition" or if Ken had not chosen to "disagree"? If we had used a debate
format from the outset, with each person taking a different side, could we have
reached this point earlier? Catherine Bateson said at a recent conference that
to have the kind of improvisational conversation she finds useful, people first
have to establish that they have a common code. So perhaps it is a matter of
stages. What do the two of you think?

In response to
Harlene's last comments, it seems to me that therapists struggling to find a
niche in managed care apparently see no other way out but to stay within the
diagnostic framework. Although I have opted out of this framework. I felt that I
should put myself back in to represent their "side." But I think Harlene is
right to say that this shift toward the medical metaphor not only distances us
from our customers but makes us less effective. Then, since no one admits to the
metaphor, we throw in mystification as well. I am glad, Harlene, that you
included such a vivid story to illustrate the dilemma.

I also greatly
liked Ken's idea of "no fault" psychotherapy. With this suggestion, he has put
himself in the category of "causal agnostic." I got this term from a recent
Nobel prize winner, the economist Ronald Coase (Passell, 1991), who pioneered
the idea that you didn't have to establish cause in cases of conflict over, say,
responsibility for pollution. If you left it to the parties themselves to figure
out, they would probably come up with a more workable solution on their own. The
idea of exchanging air rights is an example. Coases' kind of thinking, like
Ken's, starts to give everybody breathing room.

What is
especially interesting here is that what Ken is advocating is already coming to
pass. The cutting edge of family therapy is moving away from a concern with
problems and their causes. The brief solution oriented approaches that have
gained such popularity and the narrative approach of Michael White are
future-oriented, except for ways in which the past predicts what White (1989)
calls "unique outcomes." An even more extreme version of that position, of
course, is the "not knowing" stance of the late Harry Goolishian and Harlene.
The therapist who takes that stance does not concern herself with causes except
to the degree that they form part of different people's stories. She assumes
that the complaint would not have come to her attention if it had been embedded
in ways of talking that were helpful. The focus is therefore as much on changing
the style of the conversation as on what the conversation is
about.

Another idea
that I think might shake things up is to divest ourselves of the corpus of
thought known as modern psychology or the study of the "psyche." The idea of the
psyche is useful because "it" is presented as a representation of an entity
sitting inside the person like a tiny foetus. This makes it easy to think of
"it" as susceptible to failure, breakdown or distortions in growing. However,
during psychology's period of supremacy in this modernist century it has failed
to present any classification of disorders equal to that which medical research
and practice has come up with. The most cursory look at DSM IV shows it to be
built on cobwebs. This is because "invisible illnesses," as I call them, are not
analogous to disorders expressed in the body and are not, therefore, susceptible
to category and measurement. It is an exercise in absurdity to claim that they
are.

It is
interesting to think of getting rid of the whole extended family: "psychology",
"psychiatry," "psychotherapy" and the like. Ken has already done a brilliant job
in contesting many of these concepts, together with their assumptions about the
reality of the "self." For instance, he has suggested that psychology, in its
explanation for emotional distress, is wedded to a dubious belief in the stages
a so-called "psyche" must go through to be properly mature. Psychiatry, when it
is not being as medical as possible, continues to subscribe to this idea of an
intrapsychic unit, even though it is no more persuasive than Descartes' little
homunculus. As for psychotherapy, the word and what it has represented are
undergoing rapid change. Since the middle of this century, I have been watching
the course of what I call the social therapies (based on ideas about relational
difficulties) as opposed to the psychological therapies (based on assumptions of
intrapsychic dysfunction). It may well be that counseling, assuming that it is
not stamped out by managed care, will eventually end up in the social camp,
leaving psychiatry and psychology to the material world of memory, chemical
imbalance, and genes.

Calling
counseling a "social therapy" at least enlarges its scope. This widening process
started with the anti-psychiatry movement of the mid-twentieth century, for
which we may thank rebel philosophers like Thomas Szasz (1974) and R.D. Laing
(1971). Family therapy, the bastard mutant that came into being around the same
time, has been another source of change. There have been successive widenings
since that original impulse, representing an effort to include progressively
more of the social context. One could say that family therapy was only stage
one; stage two highlighted the professional context; throwing gender into the
ring moved us to the level of the society; and now the concern with
multicultural issues is pushing us to include inter-societal issues world
wide.

There is still
a conservative element in the family field which has kept a version of
developmental theory on which to base its ideas about dysfunction and cure. By
this I mean the life stage template on which various versions of what I call
"family repression theory" have been played out. This theory includes all
explanations for emotional distress supposedly caused by repressed or unresolved
memories. Family therapy orientations that locate reasons for problems in losses
that have not been grieved, anger that has been suppressed, or untold family
secrets, fall into that category. This psychodynamic template is also enshrined
in widespread folk beliefs about the relationship between expressing emotions
and mental health. But the free radicals in family therapy have always been
those who rejected the emotional repression theories for a more interpersonal
focus on communication and exchange.

In any case,
the three of us represent the position of a growing number of relational
therapists and researchers who are willing to challenge the use of labels for
mental disorder and the expansionist push to medicalize the whole enterprise.
Our hit list includes all and any diagnostic systems - biological,
psychological, or relational - that have been proposed. If we could but cease
our psychologizing, perhaps the discipline of therapeutic conversation could be
released from the grip of Newtonian science and placed under the aegis of
language arts, where we believe it belongs.